If you’re a small to mid-sized business benefits administrator evaluating add-ons to your group health plan, you’ve likely seen pitches for onsite employee clinics and direct primary care (DPC) riders, both marketed as ways to reduce employee out-of-pocket costs and cut overall group health spending. It can be hard to distinguish between vendor marketing claims and formal plan rules, especially when assessing how these benefits integrate with your existing group health coverage. This resource breaks down exactly what to confirm before signing a contract or rolling these benefits out to your workforce, with an actionable checklist to track your findings.
Direct answer: Onsite Clinics and Direct Primary Care Riders: What to Confirm
The following Onsite/DPC confirm list covers all core terms you should verify for either benefit, whether you are adding them for the first time or auditing existing offerings. All items should be confirmed in official plan documents, not just vendor marketing materials, to avoid unexpected costs or compliance gaps.
Onsite/DPC Confirm List
#### Eligibility Rules
- [ ] All employee classes (full-time, part-time, seasonal, temporary) covered by the benefit are explicitly listed
- [ ] Dependent eligibility (spouses, children, domestic partners) is clearly stated, with no unwritten exclusions
- [ ] Waiting period for new hires matches your existing group plan’s standard waiting period
- [ ] Remote/hybrid employee eligibility for onsite clinics (if applicable) is clarified, including rules for staff who only visit the office 1-2 times per month
- [ ] DPC rider eligibility for employees who do not live in the plan’s core service area is confirmed
#### Coverage Coordination
- [ ] Services provided through the onsite clinic/DPC rider count as in-network for your group plan
- [ ] Preventive services delivered through these benefits align with ACA required 100% coverage rules (no cost sharing for eligible services)
- [ ] Labs, imaging, and prescription drugs administered at the onsite clinic or through your DPC provider are covered under the benefit, or follow standard plan cost-sharing rules
- [ ] There are no penalties for seeking care outside the onsite clinic/DPC network if an employee needs specialty care or urgent care when the clinic is closed
- [ ] Coordination of benefits rules for employees with secondary insurance (e.g., coverage through a spouse’s plan) are explicitly outlined
#### Cost Structure
- [ ] No hidden membership fees or facility fees for employees using the onsite clinic
- [ ] DPC rider copays, if any, are clearly listed and do not exceed standard primary care copays under your group plan
- [ ] Services received through these benefits count towards your employees’ annual deductible and out-of-pocket maximum, per plan rules
- [ ] Employer contribution amounts for the rider or onsite clinic operations are fixed for the full plan year, with no mid-year price increases
- [ ] There are no extra charges for after-hours virtual visits offered through the DPC rider or onsite clinic
Illustrative example: If your standard group plan has a $30 primary care copay, your DPC rider may have a $0 copay for primary care visits, but labs ordered during that visit may still be subject to your standard 20% coinsurance rate until you meet your deductible.
#### Operational Access
- [ ] Onsite clinic hours align with standard employee shift times, including evening and weekend shifts if you employ hourly or frontline staff
- [ ] DPC provider network includes enough providers within 10 miles of the majority of your workforce’s residential locations
- [ ] Wait times for non-urgent appointments at the onsite clinic or with a DPC provider are capped at a stated maximum (confirm in writing with the vendor)
- [ ] All medical records from the onsite clinic/DPC provider are shared with your group plan’s care coordination team, only if explicitly requested by the employee in compliance with HIPAA rules
- [ ] Prescription refills ordered through the DPC provider or onsite clinic are compatible with your existing group pharmacy benefit
#### Compliance Rules
- [ ] Onsite clinic staff are all licensed in your state to provide the services offered
- [ ] DPC rider providers are all classified as in-network primary care providers under your state’s insurance regulations
- [ ] The benefit does not exclude employees with pre-existing conditions, per ACA rules
- [ ] All required disclosures for the benefit are allowed to be included in your annual open enrollment materials, per carrier rules
- [ ] The benefit qualifies for any applicable state tax incentives for employer-sponsored primary care access, if you are pursuing those
Common questions: Onsite Clinics and Direct Primary Care Riders: What to Confirm
Can we offer both an onsite clinic and a DPC rider at the same time?
Most group health carriers allow you to offer both benefits as complementary offerings, typically with the onsite clinic accessible to employees who work in-person at your company’s physical location, and the DPC rider available to remote, hybrid, or field employees who cannot regularly access the onsite clinic. Confirm with your carrier if there are any restrictions on offering both, or if you will need to implement a coverage rule to prevent duplicate coverage for the same employee.
Are DPC membership fees eligible for HSA reimbursement?
This depends on your specific plan design and current IRS rules for your plan year. Some DPC rider fees are classified as qualified medical expenses, while others are considered a non-qualified benefit that cannot be paid for with pre-tax HSA funds. Ask your carrier or tax advisor for written confirmation of eligibility for your specific plan.
Will using the onsite clinic count towards an employee’s primary care visit limit, if our plan has one?
Plan rules vary widely on this point. Some plans classify onsite clinic visits as preventive care that does not count towards annual visit limits, while others count them the same as standard primary care visits. Confirm this detail in your Summary of Benefits before communicating the benefit to employees, to avoid unexpected costs for staff who exceed visit limits.
Can employees who are enrolled in a high-deductible health plan (HDHP) use these benefits?
Most plans allow HDHP enrollees to use onsite clinics and DPC riders, but you will need to confirm that services offered are either classified as preventive care (which is exempt from HDHP deductible rules) or that the cost-sharing for non-preventive services aligns with HDHP requirements to keep employees eligible for HSA contributions.
What this page cannot settle: Onsite Clinics and Direct Primary Care Riders: What to Confirm
No general guidance can apply to every group health plan, so you will need to verify the following details directly with your carrier or broker, as they are specific to your plan, location, and workforce:
* Exact cost-sharing amounts for your specific group plan, as these are negotiated between your company and your insurance carrier annually
* Whether your state requires DPC riders to cover specific services like mental health counseling or urgent care visits, as state insurance regulations vary widely
* Whether your company’s onsite clinic qualifies for any ACA preventive care mandate exemptions, if applicable, for your specific workforce size and industry
* Whether adding these benefits will change your group’s overall premium rates for the coming plan year, as rate adjustments are based on your company’s claims history and carrier pricing models
* Whether DPC membership fees count as qualified medical expenses for your company’s HSA or FSA programs, as this determination is based on your specific plan design and current IRS guidance
Next verification step: Onsite Clinics and Direct Primary Care Riders: What to Confirm
First, pull your most recent official Summary of Benefits and Coverage (SBC) and group health plan contract. Cross-reference every line item on the Onsite/DPC confirm list above with the language in these official documents, flagging any terms that are unclear, missing, or conflict with vendor marketing claims. Then, schedule a call with your licensed benefits broker or health plan representative to walk through all flagged items, and request written confirmation of all verbal answers for your company’s official benefits records. If you are evaluating adding these benefits for the first time, ask the vendor to provide a written side-by-side comparison of how the benefit terms align with your existing group plan rules, so you can identify gaps before open enrollment begins.
Bottom line: Onsite Clinics and Direct Primary Care Riders: What to Confirm
Onsite clinics and DPC riders can be valuable additions to your group health benefits package, reducing employee barriers to primary care and potentially lowering long-term health spending for both your company and your workforce. The biggest risks of rolling out these benefits come from unconfirmed terms that lead to unexpected costs for employees or compliance gaps for your company, so taking the time to verify every rule in writing is critical.
This content is for educational purposes only and is not insurance, tax, legal, or medical advice. All plan terms are subject to your official group health plan documents and state insurance regulations. Verify all details with a licensed benefits broker or your plan carrier before making any changes to your benefits offering.
